patient information in case of emergency, contact: address

Name:______________________________ Date of Birth: __________________________

Pure Life Clinic • 118 N. Killingsworth St. • Portland Oregon 97217 • Tel. 503.288.4454 • Fax. 503.288.1783 • www.purelifeclinic.com

Chiropractic/Acupuncture Registration

Patient Information

Today’s Date: _______________________

Patient Name: ______________________

Address: ______________________________

______________________________________

______________________________________

Email_________________________________

Patient SS#_____________________________

Sex/Gender: __________________________

Preferred Pronoun (please circle):

He/Him She/Her They/Their Other: ______

Age_____ Birthdate____________________

Marital Status_________________________

Spouse’s Name_________________________________

CONTACT

Home________________________________

Cell___________________________________

Other________________________________

May we leave a message? Yes No

Occupation_____________________________

Employer______________________________

Employer Phone_________________________________

IN CASE OF EMERGENCY, CONTACT:

Name__________________________________

Relationship____________________________

Phone_________________________________

How Did you find us?

□ Google

□ Yelp

□ Friend

Their name: ______________________

□ Chair massage event

□ Insurance provider

Other:_______________________________

Insurance Insurance Company______________________

ID #__________________________________

Group #_______________________________

Person responsible for this account? Relationship? ______________________________________

Is patient covered by additional insurance? YES NO



Patient History and Condition Describe the conditions/symptoms you are currently experiencing:

� Concern #1:________________________________________________________________________________

� Concern #2:_________________________________________________________________________________

� Concern #3:_________________________________________________________________________________

Condition #1 Condition #2 Condition #3 When did these symptoms begin? ________________ ________________ _______________

Is the condition getting progressively worse? ________________ ________________ _______________

Rate the severity of your pain from 1 to 10 ________________ ________________ _______________

How often do you experience these symptoms? ________________ ________________ _______________

Is the pain constant or varied in duration? ________________ ________________ _______________

Describe the pain using words below ________________ ________________ _______________

(Sharp/Dull, Throbbing, Aching, Shooting, ________________ ________________ _______________

Burning, Cramps, Stiffness, Swelling) ________________ ________________ _______________

Does the pain interfere with your….

[Circle any that apply Work/Recreation/ Work/Recreation/ Work/Recreation/ for each condition] Daily Routine/Sleep Daily Routine/Sleep Daily Routine/Sleep Does it cause numbness, tingling, or weakness? ________________ ________________ _______________

What treatment/therapy have you tried? ________________ ________________ _______________

Have you experienced this condition previously? ________________ ________________ _______________

If yes, when did you previously experience it? ________________ ________________ _______________

Has the issue resolved previously? ________________ ________________ _______________

Any additional concerns? ___________________________________________________________________ Have you ever seen a: Chiropractor? ______ Acupuncturist? _______ Licensed Massage Therapist? _______

Mark an X on the picture where you continue to experience symptoms.

List activities that are painful, such as sitting, standing, etc:

________________________________________________

________________________________________________

________________________________________________

Have you received care for your current condition? ___________ Do you have children: _______ if yes, list ages: ___________

Clinician Signature:__________________________________________ Date_______________________



Health History Have you recently experienced any of the following (circle all that apply):

Bowel/Bladder changes Significant weight loss/gain Sweats/Chills/Cough Significant fatigue

Date of Last: Physical Exam:_____________ Spinal X-ray: ____________ Blood Test: _____________ Urine Test: _____________

Spinal Exam: __________________ Chest X-ray: ______________ Dental X-ray: __________________

MRI/CT Scan/Bone Scan: ______________ Blood Pressure: ____________/Reading: _____________

List the following Description Date Falls/Major trauma__________________________________________________________________ _____________________

Head injuries ___________________________________________________________________ _____________________

Broken bones/Dislocations____________________________________________________________ _____________________

Surgeries/Hospitalizations ____________________________________________________________ _____________________

Please circle to indicate if you have had any of the following:

AIDS/HIV Alcoholism Allergy Shots Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia

Cancer Cataracts Chemical Dependency Chicken Pox Dizziness Emphysema Epilepsy Fractures Glaucoma Goiter Gout Headaches

Hernia Herniated Disk Herpes High Cholesterol Kidney Disease Liver Disease Low Blood Pressure Measles/ Mumps Migraine Headaches Mononucleosis Multiple Sclerosis Osteoporosis

Pacemaker Parkinson’s disease Pinched Nerve Pneumonia Polio Prostate problem Prosthesis Psychiatric care Rheumatoid arthritis Scarlet fever Stroke Suicide attempt

Thyroid Problems Tonsillitis Tumors, growths Typhoid Fever Ulcers Vaginal Infections Venereal Disease Whooping Cough Other:____________ _________________

None of the Above

Please indicate any significant illnesses you or a blood relative (Grandparent, parent, sibling) have had: Illness Me (M) or

Relative (R) Approximate

Date Illness Me (M) or

Relative (R) Approximate

Date Cancer M R Diabetes M R Hepatitis M R Heart Disease M R High Blood Pressure M R Seizures M R Rheumatic fever M R Emotional Disorders M R Infectious Disease M R Tuberculosis M R STD M R Other illness M R

Medications Allergies Vitamins/Herbs/Minerals




Health History (Continued) OB/GYN History:

Are you, or do you have any reason to believe you may be, pregnant? Yes No Unsure

If yes, how far along are you? _____________ Due Date? _______________

Menstrual/Birthing History:

Age of first menses: __________ # of pregnancies: ___________ Birth Control Type: Avg. length of cycle: _________ # of miscarriages: ___________ ________________ # of live births: _____________

Have you been diagnosed with:

Fibroids Endometriosis Fibrocystic Breasts Ovarian Cysts PID Other ____

Female Reproductive/Breasts (please check any that you experience now and underline any that you have experienced in the past):

[ ] Menopausal Symptoms [ ] Nipple Discharge [ ] Sexual Difficulties [ ] Vaginal Discharge [ ] Difficulty Conceiving [ ] Heavy Flow or clotting [ ] Irregular Cycles [ ] Painful Periods [ ] Premenstrual Problems [ ] Bleeding Between Cycles [ ] Libido Issues [ ] Breast Lumps/Tenderness Male Reproductive (please check any that you experience now and underline any that you have experienced in the past):

[ ] Sexual Difficulties [ ] Prostrate Problems [ ] Frequent Urination/ Nocturia [ ] Testicular Pain/Swelling [ ] Penile Discharge [ ] Delayed Stream/Retention of Urine [ ] Impotence [ ] Premature Ejaculation [ ] Post void dribbling

LIFESTYLE

Occupation: _________________________________ Hours worked per week: __________

Daily routine: a. Do you typically eat at least three meals per day? Yes No If no, how many?_______________ b. Exercise routine: ___________________________________________________________________ ___________________________________________________________________________________ c. How many hours per night do you sleep? ________ Do you wake rested? Y N d. How many glasses of non-caffeinated, non-carbonated beverages do you drink per day? __________ e. Interests and hobbies:________________________________________________________________

Lifestyle Habits (please circle all that apply)

Exercise Work Activity Habits

None Sitting Smoking Packs/day:

Moderate Standing Alcohol Drinks/week:

Daily Light labor Coffee/Caffeine Cups/day:

Heavy Heavy labor High Stress Level Y N Reason:




Do you follow a specific diet (please explain): ______________________________________________________________________________________________________________________________________________________________________

Symptom Survey *Please indicate as follows: (-) = sometimes experience OR (+) = frequently experience* __ Lack of appetite __ Excessive appetite __ Loose stool/Diarrhea __Digestive problems __Vomiting __ Belching/burping __ Heartburn/reflux __ Bloating __ Obsessive about work/relationships/etc. __ Insomnia/Difficulty sleeping __ Heart palpitations __ Cold hands and feet __ Nightmares __ Mentally restless

__ Abdominal Pain __ Laughing for no reason __ Angina pains __ Chest pain __ Sciatic pain __ Headaches __ Pain or coldness in the genital area __ Cough __ Shortness of breath __ Decreased sense of smell __ Nasal problems __ Skin problems __ Claustrophobia

__ Bronchitis __ Colitis or diverticulitis __ Constipation __ Hemorrhoids __ Recent use of antibiotics __ Eye problems __ Jaundice (yellowish eyes/skin) __ Difficulty digesting oily foods __ Gall stones __ Light colored stool __ Soft or brittle nails __ Easily angered/agitated

__Difficulty in making plans or decisions __ Muscle spasms/twitching __ Low back pain __ Knee problems __ Hearing impairment __ Ear ringing __ Kidney stones __ Decreased sex drive __ Hair loss __ Urinary problems __ Fatigue __ Edema

__ Blood in stool __ Black tarry stool __ Easily bruised __ Difficult to stop bleeding __ Asthma __ Tendency to catch cold easily __ Intolerant to weather changes __ Hay fever __ Dizziness __ Tendency to faint easily __ Other:________ ________________

**Other information you would like to report/ may be relevant to your medical history?** ____________________________________________________________________________________________________________________________________________________________________________________

-------------------------------------------Doctor’s Notes---------------------------------------------- __________________________________________________________________________________________

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__________________________________________________________________________________________ __________________________________________________________________________________________

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Clinician Signature:______________________________________________ Date_______________________

patient information in case of emergency, contact: address

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